Joint and Tendon Injections
The Role of Joint and Tendon Injections in Mobility Medicine
Joint Injections:
Most intra-articular (into the joint) injections are used to manage osteoarthritis. Osteoarthritis is literally a disease of the joint. Through a process of complex pathology, components of the joint including the lining (synovium), the cartilage, and the bone beneath the cartilage are damaged. Loss of cartilage is the severe end stage of this process. Inflammation is a key trigger for this process and therefore is a target of therapy. Intra- articular products provide inflammation control, pain management, and may slow the progression of osteoarthritis. None of these products can regrow cartilage. Because of this, early intervention is recommended to slow down the process of cartilage damage and loss.
The products Dr. Mich uses are:
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Arthramid/Synamid is a polyacrylamide hydrogel (PAAG) used for many years for soft tissue augmentation (e.g. urinary incontinence) in humans and animals. In the past decade PAAG 2.5% has been used within the joint to manage pain associated with osteoarthritis by acting as a “shock absorber.” This therapy has been used in horses (Arthramid) with moderate to severe osteoarthritis for a decade with good results and few complications. Because it is non-resorbable it remains in the joint providing relief for a long time (documentation of 1-2 years). A recent study evaluated use of Arthramid in horses early in the osteoarthritis process prior to cartilage damage and found a significant benefit. Synamid was released for use in dogs in early 2021.
Prostride- APS is a joint injection product produced from your dog’s blood using a proprietary system. The result is a concentrated solution of cells, platelets, growth factors and anti-inflammatory proteins. This product has shown efficacy in laboratory, equine, and canine studies. A two (2) injection series is recommended.
3. Stem Cells are derived from a bone marrow sample from your dog. Stem cells have been used in human, equine, and canine medicine and are intended to slow the pace of and decrease the pain associated with osteoarthritis. In limited studies there has been some evidence of efficacy (improvement) although much more work needs to be done.
4. Triamcinolone is an injectable steroid used to reduce pain and inflammation associated with osteoarthritis. Dr. Mich usually reserves this treatment for patients who are older or have end stage joint disease because multiple injections can damage remaining cartilage. Side effects may include varying degrees of increased thirst, increased urination and increased appetite. All of these resolve in days to a couple of weeks. Typically duration of effect is shorter than for other injections lasting from weeks to a couple of months.
5. Hyaluronic acid (HA) is a naturally occurring component of joint fluid. It acts as a lubricant and shock absorber. Inflammation of osteoarthritis causes reduction of HA. Hyaluronic acid is injected into joints with the intent of relieving discomfort because it improves the viscosity (thickness) of joint fluid. However, research shows that HA alone is not effective in dogs. Because of this Dr. Mich typically combines HA with triamcinolone. If your dog gets relief from the injection it may last weeks to months. Injections usually need to be repeated.
As is true in human medicine the efficacy (ability to improve clinical signs) is not known ahead of time. Some patients improve and some do not. Regardless osteoarthritis is a progressive disease requiring lifelong management using multiple therapies for best results.
Joint injection is a part of a comprehensive pain management plan which includes nutrition, physical rehabilitation, and pain management.
Tendon and Ligament Injections:
Injury to tendons and ligaments is a frequent and often missed or misdiagnosed cause of lameness in dogs. Sometimes these tissues are called “soft tissues” to distinguish them from joint and bone damage. Determining location of the injury is more challenging compared to diagnosis of joint and bone issues. A dog may present with lameness and improve with rest only to become lame again after exercise. This cycle of lameness and improvement is actually due to scarring of the structure, which weakens it further. This is why diagnosis can be missed. It’s harder to find. The longer this cycle persists the more damage to the tendon or ligament over time and the lower the probability of a satisfactory recovery. These structures are critical for stability of joints and are important in the range of motion of the joints. Therefore, it is essential to find and treat these soft tissue injuries early. Intervening the first time stops the cycle. Dr. Mich uses musculoskeletal ultrasound to diagnose these injuries.
Ligaments attach bone to bone in order to stabilize a joint. An example is the collateral ligament of the elbow. These ligaments are located on the inside and outside of elbow and prevent abnormal movement. These structures are damaged when a joint is dislocated (luxated) or partially dislocated (subluxated). A less severe injury is called a sprain in which some, but not all of the ligament fibers are damaged (grade 1 or 2 injury).
Tendons are the structures that attach muscle to bone in order to move bones. An example is the biceps tendon of the shoulder. By firing the biceps muscle the energy is translated to the bone causing the shoulder to extend and the elbow to flex. Tendon injuries are very common because when a muscle is on stretch (elongated) a bit of extra force can strain the weakest point causing tearing of collagen fibers of the tendon. A few fibers can be torn (grade 1 or 2 injury) or the entire tendon can be torn (grade 3 injury).
Grade 3 tendon or ligament injury usually requires surgical reconstruction. Grade 1 and 2 injuries, the most common type of injury, usually do not require surgery and are managed with combinations of tendon/ligament injection, LASER therapy, shockwave, activity control, and physical rehabilitation. Recovery is very slow taking 8-12 months. That said, tendons and ligaments never return to full strength. This is different from fractured bone, which not only returns to full strength, but can be even stronger after the fracture heals. So the sooner we find and treat a tendon/ligament injury the fewer collagen fibers are injured and the better the outcome.
What is injected into tendons and ligaments?
Prostride- APS and Restigen (platelet rich plasma = PRP) are products produced from your dog’s blood using a proprietary system. The result is a concentrated solution of cells, platelets, growth factors and anti-inflammatory proteins. Because tendons and ligaments have poor blood supply and few cells they are notoriously slow to heal; These components are used to stimulate or jumpstart the healing process.
Dr. Mich uses ultrasound guidance to place the product precisely within the injured structure.
supraspinatus injection
Injury treatment is a comprehensive plan. Treatment must include activity restriction and prescription, physical rehabilitation. Dr. Mich strongly advises LASER and shockwave therapy as well. These treatments improve blood flow and encourage collagen growth (synthesis). Collagen is the primary building block of tendons and ligaments.
